The Llais report, “Having a baby in Neath Port Talbot and Swansea” shares the experiences of more than 500 people who have used maternity and neonatal services in Swansea Bay University Health Board.
Based on surveys, interviews, and focus groups, the report highlights a broad range of experiences, some of which Llais say are deeply concerning.
While some families described compassionate and professional care, many others told us they felt unheard, unsupported or unsafe at different stages of their journey: especially during labour, after birth, or when trying to raise concerns.
Experiences varied widely, suggesting a lack of consistency in care quality across different teams. Several described repeating their history or feeling lost in a system that didn’t seem to talk to itself.
One person explained: “They don’t talk… the consultants don’t seem to talk to each other. If you have pregnancy-related complications, it’s a lot of legwork to chase all these people and it’s exhausting.”
Several women told of being left alone in rooms or not fully monitored and having to push for examinations.
One woman said: “I was covered in blood and left in it all… I had blood running down my legs which meant the blood went on to the bed.”
Another woman added: “I was a slab of meat left on the bed. I had one person taking my clothes off, another inserting a catheter. I was naked and uncovered. My catheter was left in for 26 hours! I had a horrific experience and just left.”
Many described their experience of a dismissive culture, where people felt their pain and concerns were not taken seriously and staff attitudes varied. Llais said they heard some reports described as sarcasm, with a lack of compassion.
“The issue is not a lack of staff. There was no sense of urgency and no kindness. It was patronising.”
“I felt like an inconvenience, patronised, and in the way. I asked for a bath and was judged for it. I asked for a pillow and was told, ‘What do you think this is? It isn’t the Hilton.’”
Llais said that some women told them they left hospital feeling unsure and doubting themselves. At the time, they felt something wasn’t right, that they were being brushed off or made to feel silly for raising concerns. It was only afterwards, when they had time to reflect, that they realised how they’d been treated. Many said they were made to feel like they were overreacting, imagining things, or not to be trusted about what was happening to their own bodies. It left them feeling confused and undermined.
“‘I just thought this is how it is. I assumed it was really painful and that you are not listened to.”
“I kept saying I was in pain, but they told me I wasn’t.”
“I had to walk two wards to get to my baby after surgery — (then) I collapsed at the reception desk.
“One of the women in front of me opposite me in the Bay, she had an emergency C-section in the middle of the night and her baby laid there screaming because she was so high. She couldn’t move and I had to get up. Having just had to see to myself and go and look after her baby because there was no one to do it. And I think that there’s no excuse, don’t care how busy you are. There’s no excuse like that, for a baby not to be fed.”
“The midwife rolled her eyes when I asked for pain relief. It felt like I was being judged for not being able to handle it.”
Although no one described an entirely positive experience from beginning to end, many families praised individual staff members whose kindness and personal care made a lasting difference. Llais say these stories show the importance of respectful, compassionate care and the potential effects that can result when it is missing.
Alyson Thomas, Chief Executive of Llais, said: “We’re grateful to everyone who took the time to share their story, many of them deeply personal and painful. These experiences must lead to action. This report isn’t about blame, it’s about listening and learning. Everyone needing maternity and neonatal care and support deserves safe, compassionate, and consistent care.
“Some of the things we heard align with other maternity reviews across the UK, including in Cwm Taf Morgannwg and Shrewsbury and Telford. The repeated nature of these concerns points to a need for system-wide learning, particularly around leadership, culture, and how services listen and respond to feedback.”
Medwin Hughes, Chair of Llais, said, “The voices in this report show both the challenges and the opportunities for change. What’s needed now is continued leadership across the system to make sure those experiences are heard and acted on.”
Healthcare lawyer Julia Reynolds says the report entirely bears out those of the families she is supporting, and that the report must accelerate urgent changes to give families reassurance that childbirth is safe in Swansea Bay.
Leigh Day partner Julia Reynolds, who is investigating medical negligence claims on behalf of many Swansea families affected by alleged failures in maternity care, said: “The Llais report makes sobering reading and frankly I am absolutely appalled that women have experienced what they describe in maternity wards in Swansea.
“The Swansea Bay University Health Boad may say that these stories are old and that the deficiencies in care are being addressed.
“We have worked with the family support group in Swansea, and there are some families’ stories that are several years old, but there are some who are reporting issues with care, and their babies are only a few months or even a few weeks old.
“The families that I have been working with, tell me that their birth experience has left them traumatised. There is now a generation of people fearful of what might await them when the time comes to give birth to their child.
“We can only hope that this report accelerates the urgent changes required, because what I have read here is sadly all too familiar to me as a medical negligence lawyer. It is unacceptable that there are such experiences in maternity care in Wales.”
Responding to the report, Jan Williams, Swansea Bay UHB Chair said: “We are grateful to Llais for this report and do not underestimate how difficult it will have been for individuals who have had a negative experience of our services to re-live that whilst contributing. That’s why we would like to once again apologise to and acknowledge the trauma and stress suffered by individuals with a poor experience or adverse outcomes. We also welcome the report’s equal balance with the good examples of care and experience, and agree that we need these to be much more consistent.”
Abi Harris, Swansea Bay UHB CEO added: “We are completely focused on strengthening our services and the Llais report recognises many of the improvements that have been made. The Independent Review of our maternity and neonatal services is imminent and the final report will be published by the end of July.
“Llais has shared its findings with the Independent Review and these will be taken into account alongside a range of other inputs, including from service users via the Review’s own engagement activities but also as a result of detailed clinical reviews undertaken by independent clinicians and the review of a raft of data on the services.
“We will respond fully to all the recommendations of all these important reports together and ensure we learn and act on them. As the Llais report shows, we are making improvements and investments in quality, services, staffing and how we listen to and act on what people tell us about their care and experience.”
Dr Denise Chaffer, Chair of Swansea Bay maternity and neonatal services independent review, said: “This report provides important feedback on some of the experiences that women and families have had when using maternity services in Swansea over the last few years; all of this vital information will form part of the independent review. Alongside our thanks to Llais for developing this report, we would also like to thank all of the women who have contributed their time and their heartfelt experiences to help improve the future of maternity services.”
